Social indicators from the Amazon show that health continues to be one of the main challenges to be faced in the region. The territory covers around 5 million square kilometers, presenting not only the barriers imposed by forest degradation but also its consequences: vulnerability and the difficulty of implementing public policies that take into account the particularities of the biome and the population, promoting development and protagonism.

The reality of bottlenecks is translated into numbers. In Boa Vista, the capital of Roraima, one of the Amazon states, the number of doctors per thousand inhabitants is 1.63, according to a survey by the Instituto de Estudos para Políticas de Saúde (Ieps) [Institute for Health Policy Studies]. The rate is the lowest in the biome and it is much lower than what is recorded in other Brazilian cities, such as Porto Alegre, in Rio Grande do Sul, which has 6.66 professionals for the care of a thousand residents.

In 2023, health policies focused on the region, developed by the Ministry of Health, aimed to create exclusive vacancies for the Mais Médicos program [More Doctors] and to enable new units of the Farmácia Popular program [Popular Pharmacy]. The Ministry also expanded the budget to reinforce high and medium complexity care, but they did not detail how much was invested. Due to extreme drought that hit the biome in the same year, part of the annual budget was earmarked to support the affected population.

Local needs

Attention to the local reality is listed as a priority for the proper development of public health in the Amazon, so much so that one of the initiatives carried out by the Ministry in 2023 was to bring forward multivaccination and the campaign against influenza - which took into account the region's climatic issues. The action is part of a series of strategies that health managers, workers and health social movements are gradually trying to introduce into the Legal Amazon Health Plan (PSal).

For them, it is essential to discuss a model of care that makes it possible to attend to users in a timely manner and to conceive of the issue of health as part of the economic and social development of the biome. The guidelines advocated by the group also aim to reduce regional inequalities and seek equity - all while taking into account the specificities of the Amazon and its inhabitants.

The project was authored by four Amazonian researchers, including Paulo Oliveira, a professor at the Federal University of Pará (UFPA), psychologist and activist for the Sistema Único de Saúde (SUS) [Unified Health System]. According to him, the region has been the target of many studies related to the discovery of diseases, but nothing focused on how to develop the region based on this process. "How can we organize primary health care in a territory where time and distance are enormous? It's a challenge," he says.

"How is a patient who is, for example, in Castelo dos Sonhos [in Pará], a thousand kilometers from Altamira, or in Breves, and has cancer, going to be seen in a timely manner? [In addition,] we need to understand that there is intelligent life in the Amazon to produce vaccines, to produce serums... we have vast knowledge of plants that can and are already being studied. We have to incorporate these workers into a production chain," adds Oliveira.

The plan also involves more targeted investment in public health in the biome. This is because, according to Paulo, there are differences in maintenance costs. "It's very different to keep a doctor in the interior of the Amazon, the town hall can't afford it without federal support. Along with this, there's professional corporatism, they only want to stay 200 kilometers from the border, they don't want to go inland. We need training to help these professionals to stay. These are important points that the Ministry is working on".

Solutions are based on traditional knowledge

Valuing traditional knowledge is seen by Paulo as a way of overcoming the difficulties present in the Amazon health scenario. "We need to understand health as a good way of living and they [traditional populations] can help both in good practices for maintaining the territory, because health is also the environment, and in the discovery of new drugs and in the concept of health vigilance, because they know how to identify risks in a more advanced way," he emphasizes.

"Their knowledge needs to be incorporated, their expertise and knowledge not with a colonizer's perspective. We need to take a pragmatic approach, looking at what will help us to be sustainable and overcome the challenges we are facing," adds the professor

Negotiations

Negotiations for the Psal are in the final stages and it is expected to be published in around three weeks, as Health Minister Nísia Trindade confirmed to Liberal Amazon. She was in Belém at the beginning of July for the inauguration of the new building for the Hepatology Section (Sehep) of the Evandro Chagas Institute (IEC), an investment of around R$7.9 million that will advance research in the region. According to Nísia, Psal represents a concern to develop the Amazon.

"In the case of public health, since the transition team, with the work coordinated by Professor Regina Barroso, from the Federal University of Pará, staff member at the University Hospital, there has been a meeting of local institutions and, after that, the Ministry of Health set up a working group that has been discussing various issues, concerning surveillance, biodiversity and its potential use for health and the strengthening of local institutions and the reduction of regional inequalities," explains the minister.

Trindade pointed out that looking at the diversity of the region is a gauge for the actions that need to be taken. "That's why we brought forward the flu vaccination schedule. We can't have a single calendar for a Brazil that is not only unequal, but also has differences from this point of view. But the plan itself has not yet been finalized, it is currently being finalized. It's also going to be discussed by the entire federal government so that it can be publicized," she added.

"First it has to be discussed with the other areas of the government and President Lula is also very committed to the Amazon issue, so we have at least three weeks to finalize this process and make it public," adds the Health Minister.

Belém bets on digital service to overcome barriers

The capital of Pará has alarming public health data. According to Ieps, Belém has the most inefficient Primary Care coverage: the figures show that less than 50% of the population were covered in 2022 - the year of the last survey. However, Belém City Hall is betting on technology to solve the bottlenecks imposed historically. In July, the administration announced the launch of a digital platform that will be able to help the population to schedule medical appointments.

Saúde Belém Digital app is part of the municipality's attempts to expand primary care. The investments focus on preventing diseases. Pedro Anaisse, the city's health secretary, highlights that efforts in this direction have already increased the number of teams that are part of the Família Mais Saudável program [Healthier Family] from 124 to 348, a measure that encompasses Primary Care. "This is an increase from 28% of the population served to 85%. We're going to complement this expansion with the digital health app".

Users

Around 850,000 users are expected to use the app. This target includes people over the age of 18 who are already registered and their underage dependents. "We already have around 600,000 people registered in our Ministry of Health registration system, which is called E-Sus. Today, our 1,700 community agents from these 348 teams are actively seeking out and welcoming the population that is not yet linked to these teams," explains the secretary.

"Within the scope of primary care, we will offer consultations with pediatricians and general practitioners, family doctors, 24 hours a day, seven days a week, and multi-professional consultations with psychologists, nutritionists and physical educators from Monday to Friday, from 7am to 7pm. The population will be able to use this tool as long as they are registered with our Family Health teams. This is a requirement, because we need to see the patient cared for within the territory covered by these teams," he says.

In total, two thirds of the population living in the capital of Pará should benefit from the new service, which is seen by local authorities as an alternative to relieving the need for face-to-face healthcare. "We understand that Belém is a pioneer of this model and, because it is a pioneer, we need to praise it and make the population aware of it so that they can use it, starting in August, when we will announce the initial date. Besides, it's an application that won't use up your data package," concludes Pedro.

Indigenous health in the Amazon needs attention

In 2023, the world witnessed the health catastrophe that the Yanomami indigenous people were suffering. In addition to the diseases that illegal mining in the area led to, malnutrition was a harsh reality. However, these are not the only problems. Recently, complaints about the situation experienced by the Madihas Kulinas people, located in the southwest of the Amazon, drew attention. Along with the lack of adequate food in sufficient quantities, the group suffers from a lack of medical care.

Investments

According to the Ministry of Health, between 2023 and the first half of 2024, more than R$2.5 billion were invested on indigenous health care in the Legal Amazon. The work is carried out through the Indigenous Health Secretariat (Sesai/MS), created in 2010. The biome has 25 Special Indigenous Health Districts (Dseis) and services adapted to the cultural, geographical and administrative characteristics of indigenous peoples.

"These units carry out immunization, oral health, food and nutrition surveillance, prenatal consultations, child growth and development, health and aggravation, promotion and disease prevention and the promotion of good living in the communities. The Ministry of Health provides air, land and water transportation to remove patients for medical consultations and emergency care and to transport the Multidisciplinary Indigenous Health Teams to specific areas," the ministry said in a statement.